Decline of Service Customer Waiver

Customer-signed waiver documenting a declined repair recommendation, acknowledgment of code violation or safety risk disclosure, and release of liability when work is not performed as recommended.

Service and Customer Details

• Service Date
  Date the recommendation was made and the waiver was signed.
• Work Order Number
  Internal job or work order reference.
• Customer Name
  Name of the customer or authorized representative signing the waiver.
• Service Address
  Location where the service was performed.
• Technician Name
  Name of the technician who explained the recommendation.

Recommended Work and Decline

• Recommended Work
  Describe the repair, replacement, or corrective action that was recommended.
• Did the customer decline the recommended work?
  Select Yes only if the customer is refusing the recommended work.
• Reason for Declining
  Select all reasons provided by the customer.
• Other Reason for Declining
  Provide details if 'Other' was selected.

Risk, Code Violation, and Liability Acknowledgment

• Issue Type Disclosed
  Select all issue types explained to the customer.
• Risk or Code Violation Description
  Describe the specific risk, code issue, or consequence of not performing the recommended work.
• Customer Acknowledgment
  Customer confirms they understand the disclosure and the consequences of declining service.
• Was an emergency shutdown or immediate action advised?
  Indicate whether the customer was advised to stop using the equipment or take immediate protective action.
• Immediate Action Notes
  Document any shutdown instructions, temporary precautions, or follow-up recommendations.

Customer Signature and Release

• Release of Liability
  Customer agrees that the provider is not responsible for issues arising from the declined work, except where prohibited by law.
• Customer Signature
  Signature of the customer or authorized representative.
• Signature Date
  Date the customer signed the waiver.
• Customer Email
  Optional email address for sending a copy of the signed waiver.